Scholars Journal of Applied Medical Sciences (SJAMS) ISSN 2320-6691 (Online) Sch. J. App. Med. Sci., 2013; 1(6):943-950 ISSN 2347-954X (Print) ©Scholars Academic and Scientific Publisher (An International Publisher for Academic and Scientific Resources) www.saspublisher.com Research Article Clinical Evaluation of Pipecuronium Bromide and its Comparison with Pancuronium Bromide Kaushal RP Associate Professor, Department of cardiac anesthesia, Gandhi Medical College, Bhopal, India. *Corresponding author Kaushal RP Email: Abstract: The study was carried out to compare the intubating conditions, cardiovascular responses, neuro-muscular blocking properties and reversal characteristics of pipecuronium bromide and pancuronium bromide. This is a prospective hospital based study. 100 patients belonging to ASA grade I or II physical status aged 18 to 70 years were divided into two groups of 50 patients each. Group 1 received pipecuronium bromide in the dose of .08 mg / kg and group 2 patients received pancuronium bromide in dose of 0.1 mg/kg. Each patient was pre medicated uniformly. Time for onset of apnoea for pipecuronium and pancuronium were 91.64+ 3.59 sec. and 118.84 + 12.53 sec. respectively. The mean time for intubation was 126.60 +12.55 sec. and 144.60 + 22.87 sec. with pipecuronium and pancuronium respectively. Mean duration of block for pipecuronium was 78.64 + 8.97 min. the block for pancuronium lasted from +36-40 min with a mean duration of block 41.60+ 5.57 min. The mean duration of maintenance dose in pipecuronium cases was 45.08 + 7.19 min., while it was 27.06 + 5.01 min in pancuronium cases. Pipecuronium patients did not show significant hemodynamic changes while hemodynamic changes were seen with pancuronium patients due to mild atropine like and sympathomimetic action of pancuronium. There was no spontaneous recovery in both groups of patients. All patients required titrated dosage of atropine / neostigmine. In pipecuronium patients, after reversal, 90% of patients had adequate recovery and scored a high score between 11-15. In pancuronium patients, after reversal, 88% had adequate recovery and scored a high score between11-15. It is evident that pipecuronium bromide provided excellent intubating conditions, negligible cardiovascular disturbances, longer duration of action, lack of cumulative action, easy reversibility of neuromuscular block with high postoperative recovery score. Thus it proves to be the ideal muscle relaxant of choice in the long surgical procedure. Keywords: pipecuronium, pancuronium, neuromuscular block INTRODUCTION As Curare became popular in anesthetic practice, The introduction of curare into clinical practice did search for other non depolarizing muscle relaxants not achieve immediate success. In USA and U.K., it without side effects of curare started. This lead to the was looked suspiciously in early fifties, use of development of series of non-depolarizing muscle neuromuscular blocking drug was associated with high relaxants. King synthesized metocurine in 1935 [2]. mortality and its use in general was avoided. Initially, Alcuronium, pancuronium, Vecuronium, pipecuronium the high mortality was attributed to “high toxicity” or , Atracurium, Mivacurium and Rocuronium etc. were impurities of the drug but it was soon realized to be the introduced later on in clinical anaesthesia [3]. improper use of curare. e.g. with ether and spontaneous ventilation without adequate control of breathing- could Aims and Objects and did result in disaster. Later, when importance of • To compare and evaluate intubating controlled breathing and carbon dioxide elimination conditions and responses to was established, the use of this drug became safe and endotracheal intubation with the concept of triad of anesthesia or balanced anesthesia pipecuronium bromide and emerged. Subsequently purified curare like, tube pancuronium bromide. curare, pipe curare, and intercostin etc were used. • To assess and compare the neuromuscular blocking characters An Ideal Muscle Relaxant should have the following of pipecuronium bromide and requirements: Non-depolarising mechanism of action, pancuronium bromide by employing Rapid onset of action, Intermediate duration of action, – Evoked potential i.e. T.D.F. by Rapid recovery, Non – Cumulative, Highly selective at peripheral nerve stimultior. the neuromuscular junction, No histamine release, High • To compare cardiovascular effects potency, Easily Reversible and Pharmacologically of pipecuronium bromide and inactive metabolites [1]. pancuronium bromide. 943 Kaushal RP, Sch. J. App. Med. Sci., 2013; 1(6):943 -950 MATERIALS AND METHODS carried for another 30 seconds and then upon Present study entitled “Clinical evaluation of availability of favorable conditions, intubation was pipecuronium bromide and its comparison with performed. Pancuronium bromide was carried in the "Department of Anaesthesiology MGM Medical College” Indore Ventilation of patient was continued with Oxygen with an object to find out the neuromuscular blocking and Nitrous oxide on circle absorber/Bain’s circuit. properties of pipercuronium bromoide recently Every 10 min. the ulnar nerve was stimulated by TDF introduced and to compare it with Pancuronium method and responses were noted. A degree of bromide. neuromuscular blockade upto extent of 90% resulted in disappearance of 4th response of TDF. Appearance of Present study included 100 patients from wide range of 4th response suggested waning of block to 50% which age group (18 Yrs to 70 Yrs) were divided in two indicated the administration of supplementary dose to groups of 50 patients each. Group 1 patients received suppress 4 responses i.e. to achieve 90% blockade pipecuronium bromide in dose of .08 mg/kg and group suitable for surgery. Thus, duration of action of 2 patients received pancuronium bromide in dose of 0.1 supplementary dose was calculated as the time required mg/kg. for appearance of 4th response. All the patients included in the study were subjected Hemodynamic measurements (Pulse, B.P.) were to thorough preoperative clinical examination and taken just before administration of relaxant and just investigations to rule out systemic disease thus, the after muscle relaxant, after intubation, and then 10 mts. patients included in the study belonged to ASA grade I and 30 mts. Later. or II Physical status. At the conclusion of surgery patient was reversed as Each patient was was premedicated uniformly as usual with atropine and neostigmine. The later drug was under : given by titrating dose against TDF response till height Inj. Artopine 0.01 mg/kg maximum of 0.6 mg/1/m. of all the four contractions were same and patient Inj. Pentazocine .5 mg/kg maxiumum of 30 mg/1/m. clinically met criteria’s of reversal. These drugs were administered intramuscularly about Post operative recovery scoring was done 45 minutes before induction of anesthesia. After arrival periodically. Five parameters were taken into account of patient in OT, besides intravenous lines, and other and a score of 0, 1, 2, 3, was given for each parameter monitoring devices, peripheral nerve stimulators were and points were graded as 7,8,9. placed in position to stimulate the ulnar nerve. High score (11-15) was safe for discharge but The height of twitch response before relaxant medium Score (6-10) needs further observation. Low was noted and all the four contractions were of almost Score ( 1-5) required intensive care and observation. same height. Patients were preoxygenated with 100% 02 for 3 min and induced with Pentothal sodium in RESULTS appropriate dose intravenously. Prior intravenous All patients included in the study belonged to ASA injection of predetermined dose of muscle relaxant was grade 1 or 2 as per American society of anaesthetists given. The period of hypoventilation/ apnoea was classification. The patients were divided in two groups covered with assisted ventilation. The time for of 50 each. Groups 1 were given pancuronium bromide appearance of apnoea was noted and recorded the and group -2 were given pipecuronium bromide as twitch height. After 60 to 90 sec. of inj. of relaxant muscle relaxants in narcotic analgesic sequence. drug, assessment of conditions for laryngoscopy and Endotracheal intubation was made. In case of favorable The clinical observations made on these 100 patients conditions, endotracheal intubation was performed and have been tabulated from 1 to 16 in otherwise situations, further assisted ventilation was Table 1: Age distribution among the patients (male/female) Age Number of patient Total Male Female < 20 15 4 19 21-30 11 14 25 31-40 12 13 25 41-50 06 13 19 51-60 03 06 09 61-70 00 03 03 Total 47 53 100 Majority of patients are between 21 to 30 years. Mean age observed was 35.53 Years. 944 Kaushal RP, Sch. J. App. Med. Sci., 2013; 1(6):943 -950 Table 2: Types of Surgical Procedure Types of PS operation Number of Patients Pipecuronium Pancuronium General Surgery 24 16 Neurosurgery 17 03 Obst Surgery 00 03 Gynaecology 03 07 Orthopaedics 06 21 Total 50 50 Table 3: Shows time for onset of apnoea Time for Onset of Apnoea Pipecuronium Panucuronium < 60 sec 00 00 61 and 90 sec 38 (76%) 00 91 and 120 12 (24%) 33(66%) 121 and 150 00 17(34%) 151 and 180 00 00 Mean Apnoes time onset ±S.D. 91.64 ±3.59 sec 118.84 ±12.53 sec Pipecuronium was administered in group -I. In 76% In Group II, in 66% patient’s apnoea occurred in 90- patient’s apnoea occurred in 60-90 sec and in 24% 120 sec. and in 34% occurred in 120-150 sec. The mean occurred in 90-120 sec. The mean time for onset of time for onset of apnoea was 118-84 ±12.53 sec. apnoea was 91.64 ±3.59 Sec. Table 4: Intubating Time Time ( Sec.) Number of Cases Pipecuronium Pancuronium 60 – 90 0 0 91 – 120 39 (70%) 15 (30%) 121 – 150 11 (22%) 29 (58%) 151 – 180 00 06 (12%) Mean apnoea time Onset + S.D. 126.60+12.55sec. 144.60 +22.87 sec.